Provider Demographics
NPI:1689954562
Name:KIM, RODERICK YOUNGDO (DDS, MD)
Entity Type:Individual
Prefix:
First Name:RODERICK
Middle Name:YOUNGDO
Last Name:KIM
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 SOUTH MAIN
Mailing Address - Street 2:DEPARTMENT OF OMFS
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1500 S MAIN ST DEPT OF
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4917
Practice Address - Country:US
Practice Address - Phone:817-702-6936
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-23
Last Update Date:2017-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR2899390200000X
TX32838204E00000X
MI2901020498390200000X
MI4301108492390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty